Background

Very often, particularly for large multi-specialty practices or a large multi-state practice using a single EHR instance, the front desk might enter the wrong payer just because that's fast and they're busy.

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Often, this is because the screen for selecting which specific plans to submit the claim to is a national-level view, not regional payer list. This can mean that when it comes time to submit the claim, that claim gets sent to the wrong plan, for example, the wrong Blue plan or something like Aetna or Molina, which have several sub-plans for Medicaid.

Substrate now supports Payer Resolution. When a claim submission is rejected or claim status fails, we'll do a lookup across similar and related payors to find the correct payer to submit the encounter to. This helps resolve things like carve-outs, TPAs, and IPAs.

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Payer Resolution also verifies the patient benefit once found, and identifies demographic errors so that you can correct them and resubmit the claim with the correct demographics. Overall, this is designed to reduce front-end errors and prevent common types of eligibility-based denials. Payer resolution is automatically available to users of the Substrate Claim Status Agent and the Substrate Eligibility Agent.

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